on true facts? An author cannot, for example, simplyassert that some person's conduct is scandalous. He orshe must first set out and explain, or at least allude to,the conduct in question (which must be true) and onlythen is it permissible to give a comment on it. Forexample, to state that a surgeon was guilty of a gutlessabdication of his responsibilities would not be defens-ible as fair comment unless the author also made clearthe basis for this comment-for example, that thesurgeon had resigned on the ground that he objected tothe introduction of new pay codes. The defence of faircomment would also not succeed in this instance if infact the basis for the comment tumed out to beincorrect and the surgeon proved that he had, forexample, retired on grounds of ill health.

It is important for authors to ensure that what theyare saying is in fact comment and not simply anallegation dressed up to look like an expression ofopinion. If the allegation, although expressed in thelanguage of comment, is likely to be read as anassertion of fact-for example, "Dr A would appear tohave broken every rule in the book"-the defence offair comment will not apply and the appropriatedefence to consider is that of justification.

The boundaries of fair comment are wide and,providing authors are commenting on true facts, theyare entitled to express their honest opinion, howeverforthright. Nevertheless, caution is advisable where anauthor is speculating about an individual's state ofmind. For example, it is dangerous to say that some-one's conduct is plainly vindictive or that a person isevidently operating for reasons of personal profit. Itwill always be hard to convince a court that suchinferences about an individual's personal motivationsare fairly to be drawn from the surrounding facts of thecase.

MALICE

Finally, the defence of fair comment, as well as thedefence of qualified privilege, can be defeated if it isestablished that the publication was made with malice.Malice in this context includes not simply spite but alsothe existence of an ulterior motive. A case of malice canfrequently be built on the fact that the writer of thepiece in question has some vested interest in its subjectmatter. If the author of a piece is a person who mightwell be regarded as someone with an axe to grind greatcaution should be exercised.

Medical Education

Trends in health care and their effects on medical education

Stella Lowry

This is the eighth in a series ofarticles examining theproblems in medical educationand their possible solutions

British Medical journal,London WC1H 9JRStella Lowry, assistant editor

BMJ 1993;306:255-8

The General Medical Council has recognised fordecades that there are problems in medical education,but little real reform has happened. In recent years,however, there have been dramatic changes in theprovision of health care services which are havingknock on effects on medical education. Here I shalldiscuss some of the strongest of these forces in moredetail and examine ways in which they can be turned toadvantage in shaping medical education.

SpecialisationThe GMC believes that increasing specialisation

within medicine and the development of postgraduatemedical education are among the biggest influences onthe way we train doctors.' Doctors cannot now make acareer in any branch of medicine in Britain withouttaking part in postgraduate medical education. Eachspecialty is controlled by a royal college or faculty thatdictates the required specialist training programmeand sets the necessary standards. As a result theundergraduate medical course no longer needs toprovide so much detailed factual knowledge aboutindividual specialties. A newly qualified doctor mustbe able to function as a preregistration house officerand have the skills to take full advantage of post-graduate education.) Realistically, the detailed factualknowledge needed to begin specialist training in mostdisciplines could probably be learnt by a motivatedsenior house officer in a matter of a few weeks at thestart of specialist training.By removing much of the factual load from the

undergraduate curriculum we can clear space fortopics like communication skills, teamwork, audit andmanagement, appreciation of scientific method, ethics,information technology, etc. All of these are relevant tomodem medical practice and provide the student withthe skills needed to continue learning beyond thesheltered confines of the medical school, and theirimportance is emphasised in the contents suggested by

Box 1

Contents ofcore curriculum proposed byGMC* Clinical method, practical skills, and patient care* Communication skills* Normal structure and function: human biology* Abnormal structure and function: human disease* People in society* The public health* Disability and rehabilitation* Finding out: research and experiment

the GMC for the proposed core medical curriculum'(box 1).

Changing role ofhospitalsHuge changes in the politics and philosophy of

health care have occurred in recent years, whichare having knock on effects in medical education(N Bosanquet, paper delivered at conference ondeveloping medical education, University of London,26-27 June 1991).3-' Much more emphasis is now puton epidemiology, the health of populations, healthpromotion, and preventive medicine. Maintaininghealth is as important as treating disease. Demographicchanges mean that medicine of old age is becomingincreasingly important.Much of our health care is now provided entirely in

the community. General practitioners have a formalpostgraduate education system of their own, and theroles of other members of the primary care team havedeveloped to provide a huge range of specialist profes-sional services. These trends have been accompaniedby changes in the way our hospitals function. Forvarious reasons, including the opportunities offered by

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new technology, cost considerations, and consumerdemands, inpatient stays are becoming less commonand much shorter than ever before. This meansthat hospitals are increasingly unable to provide theexperiences needed by undergraduate medicalstudents. Many conditions are now managed entirelyin the community or on a day case basis. Fundholdinggeneral practitioners are free to negotiate contractswith local hospitals, and many patients with commonproblems are treated locally and may never reach theteaching wards of distant hospitals. If they do they areoften there for only a very short time, during whichthey may be too acutely ill to cope with the demands ofmedical students.The development of minimally invasive investiga-

tions and treatments means that much of what goes onin hospitals is inaccessible or irrelevant to studentsand useful only to postgraduate trainees. If hospitalscannot provide enough suitable patients how canundergraduate students be taught?

Skills laboratoriesOne obvious response to the shortage of real

patients is to develop artificial alternatives. This is notnecessarily a second best option. In many professions

air pilots, for example-simulated situations arean important part of the training programme. TheUniversity of Maastricht is famous for its skills labora-tory, where students can learn and practise techniquesof physical examination, interviewing skills, andinvasive procedures without causing undue stress topatients or themselves. A skills laboratory may containanatomical and clinical models for practising tech-niques like venepuncture, suturing, and resuscitation;prosected specimens and prepared slides to illustrateanatomy and pathology; computer based self directedlearning packages; and video equipment for practisinginterviewing techniques. Ideally these facilities areavailable to all health occupations, so emphasising theteam approach to medical care and helping to removebarriers by encouraging students to learn together.Many British medical schools are developing skills

laboratories. Dr Jane Dacre, of St Bartholomew'sHospital Medical School, London, emphasises theirvalue in allowing early practice of difficult, painful, orembarrassing procedures. Access to skills laboratoriesshould ensure, for example, that the first time a doctorpasses a urinary catheter is not in the middle of thenight, without supervision, and faced with a distressedpatient. Dr Dacre does not think, however, that

Are teaching hospitals still the best placefor undergraduates?

Box 2

Some advantages ofusing simulated patients* They are always available, so teaching can be betterstructured and less opportunistic* They are less liable to fatigue than real patients andcan be used over and over again* Staffand students can talk freely in front ofthem* Student anxiety is reduced* Complicating and unrelated problems that mightconfuse a student do not occur* Simulated patients can adjust their performance tosuit students with different levels of experience* They can be trained to provide feedback on how thestudent performsSome of the 'problems" that simulated patients overcomemust be coped with in real medical practice, so they cannotwholly replace realpatients in medical education

the models available are yet of such a high standardthat they can completely replace real patients inundergraduate training. But she believes that as thedemand grows and schools work more closely withthe manufacturing companies to ensure authenticityundergraduates are likely to receive increasingamounts of their practical experience in skills labora-tories.

Simulated patientsAnother response to the shortage of real patients is to

use simulated ones. In the simplest form these are realpatients with stable physical signs who are willing totake part in clinical teaching and examinations and whohave sometimes undergone simple training in how topresent their problems to students. More usually,however, the term is applied to healthy people whohave been trained to reproduce features ofreal patients.Simple briefing can enable a simulated patient to beused for practice ofhistory taking, clinical examination,and skills like getting consent for surgery and breakingbad news. More extensive* training can produce asimulated patient who gives a consistent and con-vincing presentation of a specific medical condition,often to the extent ofreproducing findings on examina-tion. Professor Paula Stillman, of Philadelphia, whohas pioneered much of the work on simulated patients,estimates that up to 25 hours of specialist training isneeded to produce a simulated patient of this type, andextensive retraining is needed to ensure that theperformance remains consistent. Simulated patientsare paid, but none make it their full time job.

Staff and students who are used to dealing withsimulated patients claim that they are so convincingthat within minutes the encounter becomes "real."Certainly it is possible to send simulated patientsunannounced into general practitioners' surgeries andfor them to remain undetected by the doctors dealingwith them.6 In North America simulated patients nowform a major element of the teaching programmein many medical schools. In McMaster University,Ontario, Canada, they are trained to very highstandards and are used to teach and assess students'abilities to take histories and perform physical exami-nations.One perceived advantage of simulated patients is

that they can be used for student assessment as they canbe trained to provide consistent, reliable feedback onperformance and can be used many times over withoutthe worries of fatigue or distress that may affect realpatients' (box 2). Indeed, in the United States the

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Injectable training arm and male cathetensation simulator. In common with students of other prmedical undergraduates may gain much experience ofprocedures by using simulators

National Board of Medical Examiners has set up aresearch project to assess whether using simulatedpatients might provide a realistic and reproduciblemeans of assessing clinical skills in the nationallicensing examinations, which currently rely entirelyon written assessment.

In Britain simulated patients are used in manyschools but in more restricted capacities. Real patientswith stable signs are commonly used in undergraduateand postgraduate examinations, but usually withoutany training or modification of their presentation.Inevitably they take no part in marking the students'performances. Several schools use actors to helpstudents leam history taking techniques and exploredifficult topics like explaining complicated proceduresand breaking bad news. Highly trained simulatedpatients, used for so much teaching and assessment inAmerica, are essentially unknown in Britain. This ispartly because of a reluctance to believe that they canever replace real situations and partly because of moremundane matters like the expense of training andemploying them and the cultural difficulty of per-suading healthy British people to volunteer to allowmedical students to perform vaginal or rectal examina-tions on them.

Community based educationAnother obvious response to the shortage of suitable

patients in our traditional teaching hospitals is to movethe students out into the community, where thepatients and much of the health care are.89 Severalmedical schools are developing this approach. Pressurefrom bed closures led to King's College Hospital,London, transferring one of its general medical firmsto the department of general practice for teachingin the community, and this year Cambridge is tointroduce a 15 month community based option for fourstudents as a pilot project in place of their juniormedical and surgical attachments and specialty rota-tions.Although most students in such schemes are

attached to general practitioners who act as tutors forthe course, community based education is not aboutstudying general practice. It is a way of leaminggeneral medical subjects in a new setting. Studentsstudy a structured course, they may attend localminiclinics and hospital based outpatient clinics andteaching rounds, patients may be brought up to thesurgeries specially for teaching, and self leamingpackages may be devised for use on the practicecomputer systems so that students can take fulladvantage ofunstructured time.Among the advantages of such schemes are the huge

numbers of patients available, the opportunity to seediseases in all stages from initial presentation torecuperation, an understanding of the range of presen-tations of a condition and the likely differentialdiagnoses, and the chance to see how illness affects the

daily lives of patients and their families (box 3). DrNigel Oswald, of Cambridge, believes that this givesstudents a more realistic idea of what medicine is like:"It is more important to see 50 people who might haveappendicitis than five who definitely do."Among the disadvantages of community based

education are the complex planning and administra-tion needed to ensure that all students see an acceptablerange of conditions, the fact that rare conditions andextreme complications may not be seen at all, the costand logistic problems of ensuring that students canfollow their patients to clinics and hospital wards asrequired, and the coordination needed to ensure thatstandards are maintained when students are taughtin small geographically spread groups away fromthe school base. The practical considerations arenumerous. For example, when the Cambridge schemestarts only students who have their own carswill be eligible to take part. Extending such ascheme to an entire school would involve complicatedplanning of transport, accommodation, and personalsafety measures, to say nothing of the academicarrangements. Despite these difficulties Dr Oswaldbelieves that this approach can and will catchon, and he cites the extensive and highly successfulvocational training schemes for general practitionersas evidence of the discipline's willingness and abilityto organise large scale, carefully regulated trainingprogrammes.

The market economyAmong recent trends that are thought likely to

influence medical education is the emergence of amarket economy in health care provision. Providersnow expect to be paid, and services that are not costeffective may not survive. The introduction of thesechanges led to fears that teaching would take a backseat in some hospitals as managers emphasised theservice elements of doctors' work and tried to balancetheir books.3 Teaching medical students has cost

BMJ VOLUME 306 23 JANUARY 1993

Box 3

Community based educationPros

* Provides a realistic response to changes in theprovision of medical care

* Overcomes the problem that hospital inpatientspresent in only one phase of their illness (when theycan least help undergraduate students)* Allows greater availability of patients-most peoplespend more time at home than in hospital* Is useful for teaching the core skills outlined by theGMC

* Presents patients in the context of their everydaylives and in proportion to the prevalence of theirdisease

* Encourages patient centred attitudes

* Encourages self directed learning and self assess-ment

Cons* Tutors are fairly isolated and need much trainingand support

* System is time consuming* Close relationship between students and tutors maylead to role modelling, which may be good or bad* May not meet students' expectations of whatmedicine is all about

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implications for hospitals. For example, patients maybe admitted earlier than necessary before routinesurgery to allow them to be used for teaching whilethey have physical signs. Extra investigations may berequested or more complicated and experimentalprocedures used so that students can leam aboutthem. Although the NHS subsidises teaching hospitalsthrough the SIFTR (Service Increments for Teachingand Research) payments for some of the additionalcosts of providing health care in a teaching setting,there was a worry that market pressures would maketeaching hospitals unviable.

In practice, however, things are not as bad as hadbeen feared.4 Medical schools are slowly recognisingthat they too are purchasers, controlling substantialsums ofmoney in the form of SIFTR, and that they cannegotiate contracts for the type of teaching that theyrequire. A few medical schools, notably Leicester,'" arealready using the placing of their teaching contracts toensure that hospital managers take education seriouslyand provide time and resources for it to be doneproperly.

ConclusionAfter years of stagnation medical education in

Britain is changing. This is being driven not byeducational theory but by the practical implications oftechnological and political changes. Medical educatorsmust seize this opportunity and take full advantage of

these trends. By teaching in a wider range of settingsand making more use of simulated situations we canallow students to explore aspects of medicine that arecrucially important but difficult to cover in a tradi-tional teaching hospital. We can ensure the best use ofall resources by having more to choose from. Studentscan learn at a more controlled pace and in a moresheltered environment, which may be less stressful tothem and to their patients. Changing attitudes to thefunding of health care may be the first realisticopportunity that we have had to enforce high standardsin medical education.

I General Medical Council. Undergraduate medical education. London: GMC,1991. (Discussion document by working party of GMC Education Com-mittee.)

2 General Medical Council. Recommendations on basic medical education. London:General Medical Council, 1980.

3 Medical Committee of Universities Funding Council. First report of the effectsof the NHS reforms on medical atnd dental education and research. London:UFC, 1991.

4 Medical Committee of Universities Funding Council. Second report of the effectsof the NHS refo.rPts on medical and dental education and research. London:UFC, 1992.

5 Stocking B. Medical advances: the future shape of acute services. London: King'sFund, 1992.

6 Rethans JJE, Van Boven CPA. Simulated patients in general practice: adifferent look at the consultation. BMJ 1987;294:809-12.

7 Stillman P, Swanson DB, Smee S, Stillman AE, Ebert TH, Emmel V, et al.Assessing clinical skills of residents with standardized patients. Ann,l InternMed 1986;105:762-71.

8 Oswald N. Why not base clinical education in general practice? Lancet1989;ii: 148-9.

9 Oswald N. Where should we train doctors in the future? BMJ 1991;303:7 1.10 Lowry S. Medical education: VI-teaching the teachers. BMJ 1993;306:127-30.

London after Tomlinson

Undergraduate medical education

Lesley Rees, John Wass

This is the eleventh article in ourseries looking at the issueshighlighted by the Tomlinsonreport into London's healthcare and medical research andeducation

St Bartholomew's HospitalMedical College, LondonECIA 7BELesley Rees, deanJohn Wass, subdean

BM7 1993j306:258-61

Pressures from students and teachers, from profes-sional bodies, and from changes in the way healthcare is delivered are all forcing a rethink of howmedical students should be taught. These pressuresmay be more intense in London but are not confinedto it. The recommendation the Tomlinson reportadvocates that has been generally welcomed is formore investment in primary care in London. Generalpractitioners have much to teach medical schoolsabout effective ways of learning, but incentives forteaching students in general practive are currentlylow, organising such teaching is difficult and needsresources, and resistance within traditional medicalschool hierarchies needs to be overcome. Likewise,students value learning within local communities,but the effort demanded ofpublic health departmentsand community organisations is great at a time whenthey are under greater pressure than ever before.The arguments over research that favour concentra-tion in four multifaculty schools are less clear cut forundergraduate education, where personal supportfor students is important. An immediate concern isthat the effort demanded for reorganising along thelines suggested by Tomlinson will not leave medicalschools much energy for innovating.

For many years it has been apparent that the teachingof medical students within the confines of specialisthospitals suffers from many defects.' The transfer ofteaching to the community, where patients live andwork, is seen to have many advantages and has been thesubject ofmuch recent debate.2 'At St Bartholomew's Hospital Medical College about

half of all medical students are destined for generalpractice, and in other schools the proportion is higher.Several events, including the Tomlinson report, haveconverged, making the pressure for more communitybased experience for medical students irresistible. Theneed for change will not be confined to medical collegesin London alone.

Pressure for change comes from patients, students,and teachers; from public and professional bodies; andparticularly from developments in the way health careis delivered in the NHS.2A Before Tomlinson bednumbers in London and elsewhere had alreadydeclined. The length of inpatient stay had shortenedand the number of patients seen as outpatients or as daycases had increased. Teaching requirements cannotdictate bed numbers, which must be tuned to patientneed. Medical education must adapt and follow thepatients, not vice versa. This means that traditionalapprentice style teaching at the bedside will assumeless importance and that leaming in primary care,community based settings, outpatient clinics, andskills laboratories will increase.

Primary careThe Tomlinson report's major imperative is to

improve primary care in the capital-the sole tenet thathas received widespread acclaim. While welcomingTomlinson's basic premise, the capital's general prac-titioners have repeatedly emphasised that improve-ments in primary care will be achieved only if sufficientresources are made available. This is required not onlyfor practice premises but to foster a pleasant and

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